No PQRS codes? What happens if you forget to add it?

PQRS stands for the Physician Quality Reporting System. It is a health care quality improvement incentive program initiated by the Centers for Medicare and Medicaid Services (CMS) in the United States in 2006.

Medicare is moving towards a Pay-for-Performance structure where quality care should have quality outcomes. Medicare will compare your care to the care of your peers. If your care takes twice as many visits as other providers for the same diagnosis, then that will raise a red flag with Medicare for you. You can count on the fact that all other insurance companies will move in this direction soon. You can bet on it and win.

A PQRS code must be appended to a billable service. They can not go out on a claim on their own, especially after the insurance claim has already been accepted. In addition, you can’t add it to a corrected claim if you forgot to add it the first time. It must be added in the first claim submission.

If this is something that’s being used in your practice, then it would be a good idea to learn it and add it first whenever it’s appropriate to do so.

Learn more about it with the free webinar that can be viewed right on this page. Enter your information and watch it now.

Jason: Thank you, Cathy, and I think we’re ready to get started and get back to business here. So, I just broadcasted out to everybody because I saw that some people are logged into the web portion of it and not the audio portion. But I think we’ll kick off, and hopefully, they’ll catch it, and if not, they can catch the rebroadcast. So, welcome, guys, and thank you for being a little patient as we got our technical portion up. This time the presenter and I are in two separate, not just locations, but states. And [inaudible: 00:00:33] let me introduce my counterpart for today. As always, I’m Jason Barnes, and I’ve got the head of our billing SWAT team, Cathy Casbarro [SP]. And, you know, Cathy, I’m probably not gonna go over all your credentials, you know, here, but you’ve worked here for nearly a decade, correct?

Cathy: That would be correct.

Jason: Yep, and much longer than that in the building industry in various capacities. And so today she’s going to help us by talking about PQRS. So what it is, what it means, and what it actually means to bill out and stay compliant when it comes to PQRS codes. And we’re gonna start off by, you know, some of those definitions. But then we’re gonna talk about, you know, what we’ve done on the back end to help prepare for this and what you can do on the front end to actually, you know, make this a reality, should you need to in your practice. So, without further ado, we have we have a presentation prepared, and Cathy and I will kinda be going back and forth. But she is definitely your go-to, on this particular topic, so, Cathy, thank you for joining us today.

Cathy: Thank you, Jason.

Jason: And, you know, we’ll kick off by, actually, just starting to define actually what this is.

Cathy: Right, so PQRS, which used to be called PQRI which is, you know, physician quality reporting incentive, well, that incentive is now gone away. And now we have…you know, we’re dealing with PQRS. At this point now they’re really dealing with penalizing practices. But essentially, what PQRS is we are sooner than we think going to a Pay For Performance structure by the payers and by Medicare. And Medicare right now is actually working on a Pay For Performance structure. What Medicare is really looking for is quality outcomes, make sure that the treatment that the patient is receiving is quality care and that the outcomes aren’t taking forever for that patient to be well again. And for that reason, PQRS was installed numerous years ago, and now they used to incentivize practices for recording their quality measures, and now we’ve come into the time period over the last year or two where now practices are going to be penalized if they don’t report their quality measures to Medicare. That’s where we are today.

Jason: I run into a lot of…I don’t want to call them conspiracy theorists, but when meaningful use came out, Cathy, there was an incentive to use that. And we’ve seen that has led to additional audits, not in every case, but in some cases they’ve actually had to give back the money for the care that they’ve provided. And so I would imagine that would be kind of woven in throughout this presentation of, you know, there’s a prescribed amount of time that a specific diagnosis should take, and unless you’re documenting why your care is taking longer, is there a risk there? For our providers who are listening to this?

Cathy: There is a risk, and that’s why Medicare puts in guidelines, and that’s where they put in, you know, limited number of visits based on a diagnosis. You know, they’ve pre-set those roles, and, you know, that’s gonna continue to happen in this industry. Definitely gonna start seeing changes going forward in probably as soon as 2017.

Jason: Okay, great. I would imagine most of our listeners or viewers, listeners/viewers, are thinking to themselves, “Yeah, that makes sense.” But at the end of the day, making sure that you can justify the care that you’ve given and billed for is really kinda the bottom line of what PQRS is about from their perspective. Is that a safe way to sum that up?

Cathy: That’s absolutely a safe way to sum it up. You know, we have here on this slide that, you know, feedback will be used by CMS. They are looking to compare your performance against your peers, and they are going to make that payment structure. And I’m telling you now, they absolutely are working on those plans as we speak.

Jason: So, yeah, let’s get into the nuts and bolts of it then, right?

Cathy: Yeah, so, I mean, Jason, we always, you know, describe things as really “What’s the problem?” And people can say, “Hey, you know, PQRS is the problem. CMS is the problem.” But really what it is is the problem across the industry, where they’re seeing where maybe a practitioner in California can get a patient better with a low back pain diagnosis and 6 treatments, where a practitioner in New Jersey has to take 16 visits for the same diagnosis. You know, why is that? So this is where they’re gonna start comparing the peers, really, across the country to say, “Listen, does it take 6? Does it take 12? What does it take?” But in the meantime, as they’re trying to figure all of that out, that requirement that we have to provide to CMS if we do not is now gonna cost our practices money.

Man: That’d be great [inaudible: 00:05:40].

Cathy: Okay, now it’s gonna have a financial impact on all of our practices if they don’t comply with the guidelines that CMS is putting in place.

Man: Yeah, that’d be great.

Cathy: So, in this case what we have here, so in 2016, 50% of your eligible Medicare patients you have to report the PQRS on. Now, there are specific measures for specific specialties. For PT, we have six reporting measures, nine for OT, one for speech-language pathologist. We have over 15 for mental health, and we have about 3 or 4 for chiropractors. So there are preset number of reporting requirements for the specialties that we have with us. Again, in this case now, if we don’t report in 2016 it’s a 2% reduction on your Medicare allowable. I know there’s some confusion out there to say, “Well, it’s 2%. You know, it’s just 2%.” Now, it’s 2% off your allowable, so you’ll see in your Medicare remits that 2% reduction off the initial allowed amount, not 2% off the 80% that they’re actually paying when they do the math.

So that can get very confusing to practices because they really are taking 2% off the top, and they’re really not playing around with that. And this is gonna continue 2016, 2017, and what’s happening is that we are not sure of what measures they’re gonna to have for 2017. We know the here and now. We know what 2016 measures are, when November, December of 2016 hits, we’ll then be provided with the 2017 measure, so these can absolutely change. I will say, though, over the past years we’ve seen some measures that have actually stayed consistent throughout specialties.

Jason: Well, there’s one consistency, right, that there will be some inconsistency at some point.

Cathy: The consistency is that there will be inconsistencies, absolutely, yes. Absolutely.

Jason: I don’t mean to speak in cliches here today, but, you know, everyone here can bank on the fact that if it’s not working, there’ll be changes made, right?

Cathy: It’s absolutely gonna happen. You know, we’ve seen that in some other things. Right now for meaningful use, I know we’re not talking about that state, but it’s a perfect inconsistency. They’ve decided that this point now to actually just rename meaningful use because it wasn’t consistent. And they’ve actually changed the guidelines for 2017, which I know we’ll be talking about later this year, but you know what? The consistent part is that it’s inconsistent, and it will change.

Jason: Yep, and meaningful use was a big, big project, and it didn’t roll out too long ago in the scheme of things, and it’s been turned on its ear.

Cathy: Yes, absolutely, absolutely. So, again, you know, we always say, “Why is the problem important to us?” Really, the problem is important because they are taking the money off the top. You know, in this case, if you’re seeing a high volume of patients or whatever it is, it’s about losing that revenue. Why continue to lose that revenue? You know, if you can just report those PQRS codes, you understand your measures, you have the guidelines in place, you know what? I’m pretty sure you wanna keep that money in your practice and not give it back to the government. By not reporting PQRS, you pretty much are just giving them that money back.

Jason: So de facto requirements, basically. If you wanna get paid for all the work that you’re doing, you don’t have a choice.

Cathy: Right, you don’t actually have a choice. So, again, a lot of these problems are always difficult to solve. Why? Because the guidelines aren’t clear. Sometimes they’re late with providing us the guidelines. It’s that inconsistency there. You know, it’s the delay of getting to find out early enough what those measures are, putting them into places as quickly as physically possible, understanding what is required for those measures in order for you to report the PQRS. Again, those PQRS codes are actually going over to the industry.

CMS, if anyone doesn’t know, the CMS is actually not the ones that are actually recording the PQRS. They actually don’t monitor those totals. There’s a separate company altogether that actually is the one that handles all the PQRS measures and gathers all of that information. So even if you were to call CMS and say, “Hey, do you have my PQRS codes?” They’re gonna say “Yeah, it’s on the claim, but I don’t know if it’s recorded because we don’t handle that.” That’s another problem because you actually have to call another company to find out that information. And, again, we always suffer with the memory management problem. Having to remember Functional G codes, PQRS codes, you know. Well, now, again, we have ICD-10 and, you know, we help our practices crosswalk from ICD-9 to ICD-10, but I really can’t easily help you cross walk PQRS Codes, you know, from your actual treatment. That’s all based on the guidelines that are written down by CMS.

Jason: But making sure that all of the codes actually get billed out, we’re able to help in that area, Cathy?

Cathy: Absolutely, yeah, we wanna make sure that if you’re gonna do this that we’re gonna assist you. And I’m absolutely gonna get over to that, Jason, about how we can help on the back end and make sure that if you wanna get involved in this PQRS, that if you’re missing it, that we’re here to remind you that you’re missing a PQRS Code, and you really wanna append something like.

But first, wanna go through really what PQRS measures we have. So for Chiropractic, actually, we have two. We wanna avoid the 2018 adjustment. We’re gonna hope that your, you know, practices have already been doing PQRS, because in this year it’s a 12-month reporting period. In this case, 50% of their patients have to be reported in 2016, and it says measures with 0% performance rate will not be counted. Essentially, if you do not have anything, it’s not recordable, it’s not gonna count, so the rules are getting harder.

For PT/OT and speech-language pathologies, if you noticed, there’s definitely a wider range here of ones that they can use, except for speech language pathology, where you get one. PT/OT kind of cross share some of the measures together between BMI medications, pain assessment, you know, plan of care on falls, functional outcomes. All of those can be shared along PT and OT as well. Mental health, again, same thing, one of the three measures have to be reported. Mental health is a little bit harder because not only do they have three of the measures that they can report on, they actually have, what we call, cross codes that they need to use. So they actually have to do a couple different sets of PQRS mapping. They get to pick one of the three in the beginning, and then they need to pick one from a separate list as well.

Jason: Eerily similar to meaningful use in a couple of different ways, but, again, different in the effect that, again, they’re gonna take the money upfront, as opposed to, you know, after the fact where they’re gonna go look at your documentation, see if it matches, you know, everything that you did and then, in an audit, take your money. Here you’ve got to get this done correctly up front in order to not receive the penalty.

Cathy: That’s correct.

Jason: So I don’t know if we can say it enough times.

Cathy: Well, it’s simple, Jason. They don’t send you a letter saying, “Can we have our 1% back?” They just take it off the top in an ERA, and you know what? It’s gone.

Jason: Yep, so, you had your allowed amount before, where you thought you were gonna get X number of dollars, and now it’s not gonna be there.

Cathy: That’s correct, right. There is no “Hey, here’s a letter. We wanna audit you. We’re thinking of taking back this money.” That doesn’t happen. This is a front end. You’ve lost it already. So, again, just to extend a little bit further here, mental health is a quite lengthy subset of codes that need to be done. So really getting into claim example, I’ll briefly run through this. It can be complex, but essentially, really what it does, it does show that your PQRS codes need to be appended to a, what we call, a billable service. Let me say that again. A PQRS code must be appended to a billable service. PQRS codes cannot go out on the claim on their own. They will not be acknowledged, so only if you have a 989 code, a 9921 code, you know, a 97014 code, a billable code with a PQRS, if you say you forgot it, and that claim is already accepted by Medicare, you should not and cannot send a separate claim with the PQRS code hoping it will be appended. Because it will not.

Jason: So a corrected claim would be the only option there, right?

Cathy: Corrected claim is also difficult as well. They will not take PQRS on corrected claims because CMS does not maintain the PQRS code. It’s not them.

Jason: So nearly a one and done situation, if I’m reading you correctly.

Cathy: You know what? And I hate to say this, and we have on the SWAT team we run into these situations where we get, you know, [inaudible: 00:15:47] on our [inaudible: 00:15:47], saying, “Hey, providers concerned their PQRS codes didn’t get accepted by Medicare.” And we go look at the claim, and that’s all they sent. And we said, “There’s nothing we can do. The guidelines are very specific to say with a ‘billable code.'” Okay, so if you forget, always think twice. But, you know, great…to your point, Jason, talking about before is how do we help, right? We want to prevent you from having to go back and say, “Oh, I forgot it. Let me go send it. Oh, now, wait, that doesn’t count.”

We have schedulers that can be put in place for your Medicare patients so you can be alerted, your front desk can be alerted. “Hey, we have a Medicare patient coming in. Let’s think about that PQRS code. Let’s make sure we get those on there.” The other ones are validations. A validation is essentially a rule. It says if we have a certain type of criteria, do something. So essentially, what we have for our practices is we have a validation that says, “Hey, this practice, A, wants to append PQRS codes.” Now, if they have a Medicare patient, and they’re sending out a claim to Medicare, of course, with Billable Services on it, and there’s no PQRS code, we can stop that claim before it gets out to Medicare. We call them validated.

If any of you have seen claims on your workbench and invalid, it’s exactly what would happen here, and the message would be very clear. It says, “Hey, you’re submitting a claim to Medicare. You asked us to stop this. If you’re missing a PQRS code, this is your chance to add it before you get it out the door. Because, again, going back after the fact is not an option.” So, these are great tools to implement any practice, to put it on the alert, you know. Say, “Medicare patient, everybody watch this one. You know, put a note on the on the patient’s account somewhere.” And, again, to stop the claim just in case we fail in the first two areas of one, on the front desk where billing out the patient, you know, we miss the PQRS, getting that claim to the workbench to take one last look at it, append that PQRS Code, if it’s missing, and getting out the door right the first time.

Jason: So, the only real risk, if you forget to put the PQRS Code on there, is that your data service might not get billed as timely as you would like it to be? It’ll hit the workbench, remind you that you need the code on there if you get through it same day, great. There’s really no lag-time that you experience, but, you know, if it takes you a day or two to get to it, that’s really the only downside.

Cathy: That really is the only downside, and, you know, Jason, you really just talk in my language about backlogs to zero. I don’t like to see claims sit an extra day. I like provider claims workbenches to be zero every day. I don’t expect somebody to remember what the PQRS code was from two, three days ago. I expect them to remember today.

Jason; I hear you, and Cathy, I have to interrupt you for a second, though, because a lot of our listeners here are not our clients, so the language that you speak, I wanna make sure it’s clear to everyone. You’re not using a system like Vericle, let’s just say. You know, how are you managing this somewhere else? And if it’s not clear to you, come talk to us. Let’s see if we can help you. But if you are one of our clients, and you look at your provider claims workbench, and you see anything over the number zero at the end of the day, you know, be concerned, be very concerned. And you should reach out to us too, have us help you figure out how to drive that one to zero because we don’t wanna add any additional claims there that are just gonna sit and wait. We want to get them all taken care of so they can get paid, right. Sitting in your workbench, they’re not gonna get paid. They’re gonna have to get to the payer.

Cathy: Right, and, you know, in any system, Jason, you know, whether you’re working off a tickler file or, you know, working off of any file in order to review those claims before they go out the door, it’s always a great idea to, you know, put a stop in place so that somebody can review it. And, you know, realize that you are have to do it for 2016 dates of service. You know, Medicare will allow claims submitted after December 31, 2016 as long as they have 2016 dates of service up to a certain point in 2017 to count. So, you know, it’s again making sure that things are not sitting out there too long, even towards even the end of the year. And I know we’re currently in May, but I’m still talking about December of 2016. You don’t want anyting sitting out there too long where you could have made that 50%, but you didn’t look at those claims. So three weeks into 2017, and now you’ve completely lost it. You’ve lost everything.

Jason: Yep.

Cathy: So, again, you know, our next steps, Jason was very clear about that. If you need help, you know, definitely reach out to us, making sure that you are reporting all your claims-based required measures that you need to for 2016 for your 12-month period. Again, if you haven’t started, you know, you might be in trouble already. But 12 months… Make sure that you review the requirements for each measure. CMS just put out the guidelines for each one, very specific, how those codes should be recorded, and they all have criteria. You can reach out to us if you’re currently not using our system if you need help, as Jason mentioned.

If you are a client of ours, definitely reach out to your practice success coach, ask him to turn on the rule for the PQRS. Talk about setting alerts on your schedule so that you can start appending those codes as soon as possible. Or if you are and don’t have the alerts, it’s a great time to implement them. Same thing we say to any practice is, “Always review internal audits. Make sure you have compliance programs within your practice so everybody’s following the same guidelines, and everybody understands the PQRS codes.” So, that would be great for all of your internal staff to be aware of all the PQRS codes. Everybody understands the guidelines. Everything is shared so that you’re all applying the same ones. So, again, if you haven’t done so, talk to your practice success coach, or reach out to us if you need help.

Jason: Yeah, so, the only question I had so far is if somebody doesn’t know where to find those codes or know what they are, where would they go within our system?

Cathy: So, within our system, you can actually do even…there’s a couple different places, believe it or not. So, we do like to put those PQRS codes to be available to practices on their travel card as part of their CPTs that they bill. We have a tab there for PQRS for Cairo, PQRS for PT/OT and PQRS for mental health that are available. If they wanna search out specific codes, they can do that through search procedures, and they’re able to find the codes there as well.

Jason: Got it.

Cathy: So we do make them readily available on the travel card for our practices. We wanna instill the use of them, and that’s why we’re putting them there for everybody.

Jason: So, the follow-up question to that was, so, if I open a ticket, somebody will help me configure my travel card? And the answer to that question is yes. We will absolutely do that. So…

Cathy: Absolutely.

Jason: We would be happy to do…

Cathy: We’d be happy to turn on the rules. We’d be happy to help you with the alerts. We’d be happy to make sure that everything’s there and ready for you to use. Now, a follow-up to that, Jason, is that if you really want to understand more about the actual codes themselves, really print out the guidelines and be able to read through them, you know, the ACA has them. The APTA has them. The APA has them, and CMS has them. All these specialties are driven to the specific PQRS codes that are for their specialties. So American Chiropractic Association, if you were to go to theirs, they’ll tell you and give you the guidelines for each of the PQRS measures available to chiropractors, the same with physical therapy and the same with mental health.

Jason: I’d like to thank the doctor who typed in the questions, very helpful, and somebody else just typed in “That’s what I was going to ask.” But those are the only questions that we have so far Cathy. That’s it.

Cathy: Okay.

Jason: So we’ll open this up to anybody else who has any additional questions, and, you know, we’d be thrilled to answer them. So, we usually give it a minute or two, Cathy. I know you haven’t been on this particular format. Obviously, you’re not a stranger to webinars.

Cathy: I’m not a stranger to [inaudible 00:24:50], but I will tell you it’s been a while.

Jason: That’s all right. So, we usually just give it another minute or two here. I know with the meaningful use, right, this was…okay, I’m sorry, but I’m not gonna finish that sentence because I had another question. What if I’m not a chiropractor, how does that affect a natural path or acupuncturist?

Cathy: So, acupuncturists as well, I don’t…last guidelines that we read acupuncturists are not required to report on PQRS. If it’s somebody that is with…you know, is one of our practices, absolutely open up a task to your coach, and we’ll go ahead and give you the printed guidelines to say that you don’t need to report on PQRS. It is in the CMS guidelines.

Jason: I do know that this person is one of our clients, so yeah…

Cathy: Okay, yeah. Absolutely get a task so we can give it to you in writing. This way there’s some peace of mind there.

Jason: So, yeah, we’ll make sure we get that done. Is there a, like, rule of thumb, Cathy? Like, if you have an MPI number then you could be affected, or if you don’t have an MPI number you’re not?

Cathy: If you do have an MPI number, you could be affected. If you don’t, you may not be, but, again, those guidelines do bend, and sometimes they’re trying to say, “Well, maybe the entire group has to report.” Which then would include everybody. So if they do have an acupuncturist in the office, we wanna be very…look at the practice as a whole and then look at that acupuncturist as an individual and provide those guidelines.

Jason: Got it, got it. Thank you. I hope that answers your question.

Cathy: They’re probably just going, “Whew.”

Jason: Well, I mean, this stuff’s complicated, right, and just hearing it once sometimes doesn’t get the job done. Sometimes you have to look at it a couple of different ways. They typed in a “thank you.”

Well, again, each time we’ll leave it open. If there are any other questions, we will do our best, and guys, when I mean we, Cathy will do her best to answer that question. All right, well, Cathy, thank you so much for joining us today, and we will adjourn then, and we look forward to seeing everyone next week.

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